In the current medical, legal, political, and fiscal health care climate, it is often difficult for nursing homes to make and implement reasoned, compassionate decisions about the appropriate type and location of care for nursing home residents. This project is a randomized trial of the introduction of and staff training in the use of decision-making guidelines for hospital transfer for residents in nursing homes in New York State. Fifteen of 30 randomly selected nursing homes will receive intensive training in the use of previously piloted guidelines. Working with the Department of Health, Office of Continuing Care, this 3 year study will test whether the introduction and use of a new model for deciding when to transfer a resident to the hospital will result in the following: A higher proportion of residents will experience an appropriate transfer; A lower rate of hospital transfers from intervention homes; A higher proportion of deaths will occur in the nursing home; families will report greater satisfaction with end-of-life care; Families will report greater involvement with transfer decisions; and Nursing supervisors will report higher levels of satisfaction with and quality of hospital transfers. Data will be obtained from chart reviews, NY State's DOH, OCC databases and interviews with nurses and next-of-kin of nursing home residents.